Background: Frequent occurrence of renal dysfunction without azotemia in patients with decompensated cirrhosis, and its prognostic and therapeutic importance, are not well appreciated.
Methods: Creatinine clearance (CrCl), 24-hour urinary sodium excretion, fractional excretion of sodium, and urine flow were estimated in 68 non-azotemic uncomplicated cirrhosis patients; all these patients were followed up for a period of 6 months. Eighteen patients with ascites and edema were treated with large volume paracentesis without colloid replacement and renal function was evaluated before, and 48 hours and 7 days later. Eight patients with abnormal CrCl were treated with 10 mg of enalapril daily and CrCl estimated at the end of 7 days.
Results: Of 68 patients, 22 had CrCl > 80 mL/min (Group I), 21 had CrCl of 50-80 mL/min (Group II) and 25 had CrCl < 50 mL/min (Group III). Renal dysfunction correlated with Child's class. During a mean follow up period of 180 days, patients in Groups II and III had higher mortality rates than those in Group I (23.8% and 36.0% vs 9.1%; p < 0.001). Following large volume paracentesis, CrCl decreased at 48 h and continued to be low at the end of 7 days even though blood urea nitrogen and serum creatinine remained normal. CrCl improved with 10 mg enalapril at 7 days (46.5 +/- 15.4 to 73.2 +/- 19.7 mL/min; p < 0.05).
Conclusion: More than two-thirds of patients with advanced cirrhosis have abnormal CrCl despite normal blood urea nitrogen and serum creatinine; they also have a higher mortality as compared with patients with normal CrCl. CrCl decreases after large volume paracentesis even though blood urea nitrogen and serum creatinine remain unchanged. Enalapril improves CrCl in patients with liver cirrhosis but its exact clinical utility needs further evaluation.